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Caring For The Caregivers

<![CDATA[The nurses’ station at Memorial Sloan-Kettering Cancer Center’s Surgical Day Hospital and Center for Image-Guided Intervention, New York, designed by Jeffrey Berman Architect, has limited points of public access and workstations in the rear that are meant to be private areas where staff can catch up on charting, paperwork, and other quiet work. Photo: John Bartelstone Photography, courtesy Jeffrey Berman Architect. ]]>

Focusing attention on the needs of caregivers benefits patients and healthcare staff.

The nurses’ station at Memorial Sloan-Kettering Cancer Center’s Surgical Day Hospital and Center for Image-Guided Intervention, New York, designed by Jeffrey Berman Architect, has limited points of public access and workstations in the rear that are meant to be private areas where staff can catch up on charting, paperwork, and other quiet work. Photo: John Bartelstone Photography, courtesy Jeffrey Berman Architect.

By Kenneth W. Betz, Senior Editor

Much has been said about the patient experience in healthcare settings. Until recently, less has been said about the caregiver experience, but that’s currently changing. In fact, many think the two are not mutually exclusive.

Milly Baker, AIA, LEED AP, ACHA, senior associate, Payette architects, Boston, related having managed a facilities department at a teaching hospital where it was not unusual for senior staff with tremendous responsibility (such as an ICU nurse manager) to have 75-sq.-ft. windowless office on a unit with inadequate teamwork space and depressing break space.

“Staff are under tremendous pressure; they are caring for families during often tragic situations where mental and physical strength and endurance are at a premium. Nurses work in challenging physical environments where facilities often fall short on supporting the needs of the staff,” she said.

Baker continued: “Emerging research has quantified the relationship between environmental factors and productivity. There are tremendous advantages to designing better spaces for staff in measurable gains in reducing sick days, improved job retention, and fewer mistakes. But the forces against expanding and improving staff spaces are also strong. The overall high cost of building construction ($1000/sq. ft. in the Boston area) combined with competing project priorities means that space is always a scarce resource and daylight often emphasized for patient and family spaces. In order to preserve quality spaces for staff, senior administration must recognize both the need and the consequences of design decisions.

“There are many opportunities for improvement,” Baker said. “ If identified and prioritized from the beginning, staff space can be appropriately sized and placed. The leading concerns for staff are: respect, security, collaboration space, respite, and the ability to offset grief and stress with diversions.”

“Respect begins the list because staff look for acknowledgement that they are being given the right tools to perform their jobs successfully, and the right tools include appropriate work space which provides some level of privacy. At the very least, staff should have access to a place to place their personal things, whether an office or a locker,” Baker said.

A panel of architects with Tsoi/Kobus & Associates, Cambridge, MA, expanded the definition of caregiver to family members, significant others, and the clinical care team. “In terms of the built environment, considerable attention has been devoted to improving the caregiver experience at multiple levels. Within the patient room, designated patient, family, and staff zones are provided to allow each party to have a sense of place and privacy, control their immediate environment, and work in a safe and undisturbed manner. Workplace redesign addresses issues related to the changing dynamics of care-team interaction and collaboration as well as the differing needs/priorities of the multi-generational workforce. Consideration for the specific and unique needs of all and how these needs can be melded into a comforting, comprehensive, and holistic environment positively influences the customer experience,” the team said. Those contributing to the discussion were Rick Kobus, senior principal; Jocelyn Frederick, principal; and Elizabeth von Goeler, director of interior design.

The Farber Center for Radiation Oncology, New York, features two high-energy Elekta linear accelerators and an HDR + Brachytherapy Suite that required shielded vaults weighing several million pounds. Designed by Jeffrey Berman Architect, the space features wood flooring with a high-tech cork underlayment that was designed like a sprung dance floor or gym floor for staff and patient comfort. Photo: John Bartelstone Photography, courtesy Jeffrey Berman Architect.

The patient experience has been front and center for many years partly because it’s the right thing to do and partly because it has financial consequences to the hospital, commented Joan L. Suchomel, AIA, ACHA, EDAC, principal, Eckenhoff Saunders Architects, Chicago. While staff costs may be a little harder to quantify, there’s no question that recruiting and training new staff is costly. Consequently, retaining staff is important to healthcare organizations, she said, noting that hospitals may pursue a Magnet designation to that end. A Magnet hospital is defined as having exceptional nursing standards as well as a good work environment for nurses. Application for this status is through the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program (MRP), Silver Spring, MD.

Jeffrey Berman, AIA, ACHA, principal, Jeffrey Berman Architect, New York, agrees that quantifiable is good as far as it goes, “but one of the things that so many designers and institutions don’t look at is really a work/life issue. The staff assigned to these facilities spend two-thirds of their day at work, so the quality of the environment and the support they get from the facility is key.”

The level and quality of care is very often a function of how good the working environment is, not just how good the patient environment is, Berman continued. “It’s easy to do a nice waiting room and make things look bright and pretty and open, but it’s also about how we support the medical staff, the providers, the nurses, the doctors, whose job has become significantly more complicated from a technical and medical standpoint, but it’s also harder in terms of just work flow and processes,” he said.

A pocket park created out of a tiny corner of the Boston Children’s Hospital campus adjoins the Mandell Building, designed by Payette. The Mandell Building is located on a dense urban site and the design team introduced connections to nature wherever possible for patients, staff, and visitors. Photo: Warren Jagger Photography, courtesy Payette.

Physical injury

“Additionally caregivers should not be put in the position of injuring themselves in caring for patients. Patient lifts, adequately sized bathrooms, and height-adjustable exam tables all contribute to a safe work environment for caregivers,” Baker said.

During the design phase of the Barnes Jewish Hospital, St. Louis, HealthCare campus transformation study, numerous studies were accessed to understand how slips, falls, and back- and lifting-injuries occur, according to Tsoi/Kobus & Associates. Several key aspects are design specific.

Flooring material obviously is crucial to preventing slips and falls. Among factors to consider:

• How difficult is it to push a cart, bed, or equipment on it?
• Is the pattern of the flooring material creating a depth-perception issue?
• Are transitions between different materials seamless both from a height as well as maintaining cadence perspective?
• Will the material be slip resistant when wet?

The emphasis on healthcare flooring until recently has been that it has to perform. “I think traditionally we’ve defined performance as it has to be durable and maintainable, and the patient or resident has to be able to ambulate or move around on it. That’s all the industry ever expected,” said Mark Huxta, healthcare director of sales, Ecore, Lancaster, PA.

That thinking has shifted, Huxta thinks. “Maybe a floor can do more. It can be part of the solution when it comes to patient safety and reducing risk of injury from a fall. It can enhance the quietness of the healing environment by providing acoustic properties, and it can increase staff comfort. There are new expectations,” he said.

Comfort underfoot is appreciated by nurses who spend long hours on their feet, in some cases walking as many as several miles a day in a single shift. A flexible material that absorbs the pressure of footsteps can add to that comfort, according to Tim Cole, vice president of marketing at nora systems Inc., Salem, NH.

“It helps to alleviate the pressure constantly placed on the joints and reduces many of the complaints associated with heel pain, plantar fasciitis, shin splints, knee pain, hip pain, and lower back pain, complaints common among nurses. And less pain translates to happier nurses who are less fatigued and better able to concentrate on the tasks at hand and the patients in their care,” he explained.

Another factor that plays into staff satisfaction is the design of the patient headwall. The location of elements such as medical gases, electrical outlets, and nurse call systems should be designed to minimize staff from bending too low, reaching too high, or reaching across the patient. During planning, mock-ups of the patient headwall will allow the clinical team to discuss and refine the specific locations for all of these devices, improving and potentially standardizing the headwall design throughout the institution, Tsoi/Kobus advised.

This is an unassigned office/touchdown station where staff can get focused work done at Univ. of Massachusetts Medical Center, Ambulatory Care Center, Worcester, MA. The building was designed by Payette for the Univ. of Massachusetts Medical School. Photo: Rachellynn Schoen, Payette.

Patient lifts and transfers often can result in injuries to the patient, staff, or family. Often, the patient or family will try to move themselves rather than wait for assistance. Improper lifting by staff can result in injuries as well. According to Tsoi/Kobus, “This risk can be mitigated through the installation of lift mechanisms, furniture that will allow for the re-positioning of the patient prior to transfer, or locating alcoves and lift-equipment storage areas for easy access by staff,” the firm said.

One of the biggest things in terms of staff injury reduction or prevention is the patient lift, agreed Joan Suchomel. “There are two parts to that,” she explained. “One is policies and procedures for safe handling and training.”

The mechanical patient lift is the other place to prevent musculoskeletal injuries among staff. They can be built in or portable lifts, but “we’re finding a lot more demand for them to be built in because you don’t have to go searching for a lift and drag it into the room. Some staff might conclude it’s not worth it, whereas if you have a lift right in the room they’re going to use it,” she said.

‘There are different kinds of lifts, and some are more expensive than others,” Suchomel explained. “A transverse lift can cover almost anything in the room. It can go left, right, up, or down. Then there are other kinds of lifts that are just single track. They might be straight or they might be in a J so they can specifically cover certain parts of the room. The transverse lift is more expensive but it’s more flexible. I would recommend facilities have a lift in pretty much any new patient room.”

“Another safety factor would be proper location of sharps disposal to reduce the number of needle sticks from sharps. “Some of that is regulated by either internal standards or by OSHA, but we try to make sure those are in the right place so there is less handling of the sharps,” Suchomel said.

Personal protection equipment, likewise, should be placed where it is easily accessible to the staff so they aren’t tempted to not use it simply because it’s inconvenient, she added.

During a particularly stressful shift, caregivers may want to decompress in a quiet space, away from everyone for several minutes. This break area at ProCure Oklahoma, Oklahoma City, was designed by Tsoi/Kobus & Associates. Photo: Jonathan Hillyer, courtesy Tsoi/Kobus.


Almost all clinical work involves teamwork, Baker observed. “Patent encounters involve not just a doctor but also nursing and a host of support staff. Great clinical care comes from great teamwork, and teamwork relies on communication. Sadly, many hospital designs provide inadequate space for team meetings,” she said.

“Staff should have a place to have private conversations while they’re on the job, so if they need to talk about a patient they can go into a huddle room or something like that where they don’t have to talk in front of the patient or in front of the family,” Suchomel commented.

Jeffrey Berman concurred with the need for touchdown or meeting spaces. “So much of medicine now is delivered by teams that consult a specific specialist or multiple specialists, and these groups need a place to go where they have access to medical records, lab reports, and x-rays and maybe go back and see the patient again. That sort of working meeting space is becoming a critical enabler to providing a higher-level care,” he said.

Easier visual contact with other staff also is helpful. “Usually there are technological ways to communicate between staff, but sometimes it’s handy if your hands are full and you have a patient you need help with, if you can see another staff member and be able to speak to them directly that helps,” Suchomel said.

Emphasis on clean lines of sight to the patients and to the fellow staff members is helpful, R. David Frum, AIA, president, Salus Architecture, Seattle, WA, agreed. “Maintaining a continuous observation of patients decreases stress and worry. The contact with fellow staff members assures staff they can get help when necessary, and they are able to consult with colleagues on issues they’re uncertain about,” he said.

Individual work

Collaboration has its place in medicine just as it does in an office, but some things that used to be simple, like jotting down notes on a patient’s paper chart while talking to them, are not an option any longer. Caregivers sometimes need a quiet space to work.

“You sit at a computer and pick things off menus, write notes, and document medications and other things. You really need a quiet space to do that; it’s hard to sit in a room with a patient there, and it’s hard to sit at a desk where other things are going on around you. We’re seeing documented increases in errors in charting and in medications where these things have been done in busy, open spaces as opposed to quieter more secluded spaces. You need a little quiet time to finish this without being disturbed,” Berman said.


Space in medical facilities is expensive and it is often limited. Planning for that space to be efficient and convenient for caregivers as well as patients is important. Berman recounted the challenge of a small infusion center with limited space. The nursing staff spent a lot of time on charting, records, and scheduling patients, but they also set up infusions and talked to the patients.

The dilemma was how to fit eight workstations—three for the nursing staff at a desk and five for the infusion suites—into the space. The solution was three computer workstations on wheels so staff could move from patient to patient with their computer, and then that computer ended up with them back at their desk when they were not seeing patients. In addition, the carts were fitted with the basic supplies the staff needed to start the infusions—such as alcohol swabs, needles, Bandaids—eliminating the need for a large cabinet in each infusion room. The rooms were smaller, cleaner, and neater, and the staff always had what they needed with them as they moved from place to place. It took a space that would have been small and difficult to work in and decluttered it and made it comfortable, Berman said.

Nurses’ stations at Skokie Hospital, part of NorthShore Univ. HealthSystem, Skokie, IL, have a direct line of sight to individual intensive-care units, which benefits both staff and patients. Architect for the project was Eckenhoff Saunders Architects, Chicago. Photo: Eckenhoff Saunders Architects.

Privacy and breaks

Baker emphasized that staff need areas with privacy from public areas so they can truly take a break. “The departments where staff are most challenged (such as the emergency department or medical ICU) should have particular attention to respite areas where staff can go to feel refreshed and restored. Ideally the environment provides support to grieving, exhausted, and stressed-out staff who just need to take a break. Is there somewhere quiet and private to relax? Can one find a seat with a view to nature for a mental distraction? Other potential staff supports include adequate on-call space, in-house exercise facilities, spiritual space for meditation or prayer, a place to meet coworkers for coffee or lunch, or a walking trail,” Baker said.

It’s important for staff to have break options. “During a particularly stressful shift, the staff may want to decompress in a quiet space, away from everyone for several minutes. Breaks are encouraged for staff, but oftentimes staff feels compelled to remain at the workplace. Studies have shown that leaving the specific work environment helps staff decompress and re-energize themselves. Break areas need to be designed to reinforce the staff’s wellbeing and not become an extension of their workplace,” the Tsoi/Kobus team emphasized.

Break rooms are sometimes mandated by codes, but they’re one of the amenities that sometimes get scarified to the medical program. Nevertheless, they’re important because of the pace and intensity of many healthcare settings, according to Jeffrey Berman.

Caregivers need to step out of the care venue in a way that’s both psychological and physical. If colleagues see you sitting at your desk, they’re more likely to come and interrupt you, but if you go to a designated break room or lounge, that’s a clear signal that you’d prefer to be left alone unless it’s an emergency, Berman said.

Those lounges can go from very simple coffee places to more sophisticated spaces with computers, small carrels, or workstations where people can check their personal email, make phone calls, and do things like banking without being exposed to everyone else in the facility, Berman suggested.

Another staff amenity that seems simple but which is often overlooked is lockers or other personal-effects space. “If you think about it,” Berman said, “everyone shows up for work with cell phones, purses, briefcases, and a host of other things that need to be put away in a secure, out-of-the-way space. It declutters the workspace, and people understand what they can bring to work and what they can’t.”

“In suburban areas, where people drive, they can leave stuff in their cars, but in New York City, if you commute using public transportation with a gym bag, it’s a real puzzle where to put it in some facilities. It ends up cluttering patient areas,” he noted.

Even the smallest touches can make a difference, Berman said. He described a specialty clinic where the physicians were booked into the same workroom, the same time slot, every day. The even had a drawer where they could leave a few things, maybe as simple as a prescription pad, some business cards, and a couple of pens. The same support staff was also the same every time the physician was at the facility.

“It set up an esprit de corps and a comfort level that was consistent from week to week and day to day. We got a lot of positive follow-up comments on that from people who had worked in clinics where they didn’t have a consistent space to work and they were sort of floating,” Berman said.

Having just a little control over their environment, like window shades or controllable task lighting, as well as some access to daylighting and views are beneficial to caregivers as well, Berman added.

“Healthcare design is moving towards a holistic approach that looks at programmatic needs, human psychology, and family support to heal both body and mind. Focusing attention on the needs of the caregivers reinforces the belief that patients and staff will benefit from a healthy well-designed environment,” Payette’s Milly Baker concluded.

Click here for the May 2017 Ken’s View column.

— Worker Safety in Your Hospital (OSHA)

— Facility Guidelines Institute

— American College of Healthcare Architects

— The Center for Healthcare Design

— Nursing Institute for Healthcare Design

— American Nurses Credentialing Center

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